Table 1.

Drug Selection in Hypertensive Patients With or Without Other Major Conditions

Patient Type	First Drug	Add Second Drug If Needed to Achieve a BP <140/90 mm Hg	If Third Drug is Needed to Achieve a BP of <140/90 mm Hg
A. When hypertension is the only or main condition
Black patients (African ancestry): All ages	CCBa or thiazide diuretic	ARBb or ACE inhibitor (If unavailable can add alternative first drug choice)	Combination of CCB + ACE inhibitor or ARB + thiazide diuretic
White and other non‐black Patients: Younger than 60	ARBb or ACE inhibitor	CCBa or thiazide diuretic	Combination of CCB + ACE inhibitor or ARB + thiazide diuretic
White and other non‐black patients: 60 y and older	CCBa or thiazide diuretic (Although ACE inhibitors or ARBs are also usually effective)	ARBb or ACE inhibitor (or CCB or thiazide if ACE inhibitor or ARB used first)	Combination of CCB + ACE inhibitor or ARB + thiazide diuretic

B. When hypertension is associated with other conditions
Hypertension and diabetes	ARB or ACE inhibitor Note: in black patients, it is acceptable to start with a CCB or thiazide	CCB or thiazide diuretic Note: in black patients, if starting with a CCB or thiazide, add an ARB or ACE inhibitor	The alternative second drug (thiazide or CCB)
Hypertension and chronic kidney disease	ARB or ACE inhibitor Note: in black patients, good evidence for renal protective effects of ACE inhibitors	CCB or thiazide diureticc	The alternative second drug (thiazide or CCB)
Hypertension and clinical coronary artery diseased	β‐Blocker plus ARB or ACE inhibitor	CCB or thiazide diuretic	The alternative second step drug (thiazide or CCB)
Hypertension and stroke historye	ACE inhibitor or ARB	Thiazide diuretic or CCB	The alternative second drug (CCB or thiazide)
Hypertension and heart failure	Patients with symptomatic heart failure should usually receive an ARB or ACE inhibitor + β‐blocker + diuretic + spironolactone regardless of blood pressure. A dihydropyridine CCB can be added if needed for BP control.

Abbreviations: ACE, angiotensin‐converting enzyme; ARB, angiotensin receptor blocker; BP, blood pressure; CCB, calcium channel blocker; eGFR, estimated glomerular filtration rate.

^aCCBs are generally preferred, but thiazides may cost less.

^bARBs can be considered because ACE inhibitors can cause cough and angioedema, although ACE inhibitors may cost less.

^cIf eGFR <40 mL/min, a loop diuretic (eg, furosemide or torsemide) may be needed.

^dNote: If history of myocardial infarction, a β‐blocker and ARB/or ACE inhibitor are indicated regardless of blood pressure.

^eNote: If using a diuretic, there is good evidence for indapamide (if available).